No Walk-in’s – Office will be open for Appointments Only · No Walk-in’s – Office will be open for Appointments Only To schedule an appointment, please contact the leasing

Montrose Place & Turtle Creek Apartments

“This institution is an equal opportunity provider and employer”Montrose Place Apts does not discriminate on the basis of disability status in the admission or access to, or treatment or

employment in, its federally assisted programs and activities.Section 504 Coordinator: Alison Hunsicker, 4514 Cole Ave, Suite 600 Dallas, TX 75205

T.D.D. 1-800-735-2989

All applications that are submitted to Montrose Place & Turtle Creek Apartments will be processed according to the properties Resident Selection Policy. In order to provide adequate time for each application,

In the interest of protecting our staff, residents, and community, the following procedures are effective immediately per the guidance from the CDC in response of the COVID-19 outbreak:

No Walk-in’s – Office will be open for Appointments Only

To schedule an appointment, please contact the leasing office:

2200 Montrose Place Belton, TX 76513

Office: 254-939-8126Fax: 254-933-8019

Manager: [email protected] Manager: [email protected]

Please confirm you are not experiencing any COVID-19 symptoms. If you are, we ask that you be symptom-free for at least 72-hours.

The below Required Information/regulations must be provided on application by all applicants/resident:

1. 2 Verifiable rental histories2. Employer and all income information 3. All household members’ assets4. Head of Household Must be 18 years of age5. All household members over the age of 18 years must submit a copy of their current picture

I.D.6. All household members must submit a copy of the Social Security Card of everyone who

would be residing in the apartment and birth certificates for all minors.7. Submit an application fee of $12.50 per household (USDA RD Properties ONLY).

This Must Be Paid with a Money Order. WE DO NOT ACCEPT CASH.

CURRENT RENT RATES ARE: 1 Bedroom………………….$539.00 to $614.002 Bedroom………………….$609.00 to $679.003 Bedroom………………….$744.00 to $774.00

Application not having the above information attached will be consider incomplete and will not receive priority placement. Make sure to complete and sign the entire application.

DO NOT answer questions with N/A, use NONE instead.DO NOT use white out or other correcting methods. Please mark the error s and initial.

Sincerely,Management Team

mailto:[email protected]

mailto:[email protected]

Montrose Place & Turtle Creek Apartments



T.D.D. 1-800-735-2989

Date: ____________________

I, the undersigned, understand and agree that my application for an apartment with Montrose Place Apts shall remain active only for a period of one year.

I understand that I must show a renewed interest in my application every ninety days by:

Notifying Montrose Place Apts in writing or in person that I continue to be interested in obtaining housing within 90 days.

Providing Montrose Place Apts with information regarding my circumstances such as changes in household members, income, telephone numbers and et cetera, as they change. Failure to do so will result in my application being removed from the waiting list.

I further agree and understand that if I am not housed prior to the aforementioned date and I fail to advise the property of my continued interest, in order to keep my application from expiring that said application will be removed from the waiting list. A copy of the Tenant Grievance and Appeals Procedure has been provided.

Applicant’s Signature

Note: When your name comes to the top of the waiting list, we will notify you. Until that time comes, it is your responsibility to keep in touch with this office according to the directions above.

Please check which size is needed for your household.

One Bedroom Two Bedroom

_____ Three Bedroom

Security deposit is equal to one month’s basic rentApplication fee is $12.50 per household (USDA RD Properties Only)

Key deposit $35.00

APPLICATION FEE IS NONREFUNDABLE!SECURITY DEPOSIT IS NONREFUNDABLE AFTER 72 HOURS

MUST BE PAID BY MONEY ORDER!

MONTROSE PLACE APARTMENTS

[ Lease Authorization No. : 2020TX0225 ]





Montrose Place AptsAUTHORIZATION FOR RELEASE OF INFORMATION



T.D.D. 1-800-735-2989

I/We authorize and direct any Federal, State or local agency, organizations, business, or individual to release to and verify any application for participation in USDA Rural Development, LIHTC, TDHCA and HOME in administering and enforcing program rules and policies. I also consent for USDA Rural Development, LIHTC, TDHCA and HOME to release information from my file about my rental history to Tenant Tracker, credit bureaus, collection agencies or future landlords. This includes records on my payment history and any violations of my lease or policies.

INFORMATION COVEREDI/We understand that depending on program policies and requirements, previous or current information regarding my/our household or me may be needed. Verifications and inquiries that may be requested include but are not limited to:

Identity and Marital Status Employment, Income, and AssetsMedical or Child Care Credit and Criminal ActivityResidential and Rental Activity

GROUPS OR INDIVIDUALS THAT MAY BE ASKEDThe groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to:

Previous Landlords (Including Past and Present Employers Housing Agencies) Welfare AgenciesSchools and Colleges State Unemployment AgenciesLaw Enforcement Agencies Social Security AdministrationRetirement Systems Veterans AdministrationMedical and Child Care Providers Support and Alimony ProvidersCredit Providers and Credit Bureaus Banks and other Financial Institutions

COMPUTER MATCHING NOTICE AND CONSENTI/We understand and agree the properties affordable programs may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. These agencies may in the course of its duties exchange information with other Federal Agencies, Department of Defense, Office of Personnel Management, the U.S. Postal Service, the Social Security Agency, and State welfare and AFDC agencies.

CONDITIONSI/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of the authorization is on file with the property and will stay in effect for one year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove incorrect.

SIGNATURES:

Head of Household (Print Name) Date

Spouse (Print Name) Date

Adult Member (Print Name) Date

Adult Member (Print Name) Date

Montrose Place AptsRESIDENT SELECTION PLAN

Page 1 of 10“ “This institution is an equal opportunity provider and employer”

Montrose Place Apts does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

Section 504 Coordinator: Alison Hunsicker, 4514 Cole Ave, Suite 600 Dallas, TX 75205T.D.D. 1-800-735-2989

I. Fair Housing and Equal Opportunity Laws.

A. In any phase of the occupancy process, management will comply with the provisions of Federal, State or local Fair Housing law prohibiting discrimination in housing on the grounds of race, color, religion, sex, familial status, national origin, or handicap. Other nondiscrimination provisions include Title VI of the Civil Rights Act of 1964 (Public Law 88-352, 78 Stat. 241), Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975, as they relate to the RD multi-housing program. The occupancy process includes, but is not necessarily limited to, application processing, leasing, transfers, delivery of management and services, access to common facilities and termination of occupancy.

B. Should any applicant or resident believe their rights have been violated under the Fair Housing and Equal Opportunity laws, they may contact the:

HUD, FHEO Office801 Cherry Street, Unit #45, Suite 2500

Fort Worth, Texas 76102817.978.5826

C. This Development will comply with state and federal fair housing and antidiscrimination laws; including, but not limited to, consideration of reasonable accommodations requested to complete the application process. Chapter 1, subchapter B of this title provides more detail about reasonable accommodations.

Screening criteria will be applied in a manner consistent with all applicable laws, including the Texas and Federal Fair Housing Acts, the Federal Fair Credit Reporting Act, program guidelines, and the Department’s rules.

Specific animal, breed, number, weight restrictions, pet rules, and pet rules, and pet deposits will not apply to households having a qualified service/assistance animals(s).

II. EIV (Section 8 Properties Only)

In effort to ensure the right assistance is provided to the right people, the Department of Housing and Urban Development (HUD) has provided all RD 515/8 properties within our portfolio access to a new verification database called the Enterprise Income Verification Systems (EIV).EIV has the potential to provide Management with documentation regarding any Resident currently receiving rental housing assistance from Multifamily Housing, Public Housing or a participant in Housing Choice Voucher programs using the Existing Tenant Search and the Multiple Subsidy Report. Nothing prohibits a HUD assistance recipient from applying to this property. However, the applicant must move out of the current property and/or forfeit any voucher before HUD assistance on this property will begin. If the applicant or any member of the applicant household fails to fully and accurately disclose rental history, the application may be denied based on the applicant’s “misrepresentation” of information. The EIV Existing Tenant Search will be utilized when processing an application and the Multiply Subsidy Report will be reviewed on a monthly basis. If any household member receives or attempts to receive assistance in another HUD assisted unit while receiving assistance on this property, the household member will be required to reimburse HUD for assistance paid in error. This is considered a material lease violation and may result in penalties up to and including eviction and pursuit of fraud charges. Staff will ONLY access your EIV income information at Annual Recertification, during your 30 Recertification after the initial move-in date and Management’s issuance of an Interim Recertification. During occupancy, each year as a resident the below listed information will be verified during the Annual Recertification process:

Social Security Benefits/Medicare Payments Supplemental Security Income Payments Wage information New Hire Unemployment Resident receiving multiple subsidy payments

In the event, the inquiry into your EIV income information provides management with documentation of your Household’s receipt of unreported income, you will be notified to report to the Rental office to meet with Management. In the event Management verifies the information received was not reported timely and exceeds the cumulative monthly amount of $200 or more, a Recertification Repayment Agreement may be executed for a Resident to repay any overpayment of subsidy. If a Resident knowingly provides incomplete or inaccurate information, Management may terminate Assistance and/or Tenancy.

III. Applications and Program Eligibility

Management will accept an application for rental from any and all interested persons, in person, during normal business hours. All persons desiring to apply for occupancy will be provided the opportunity to submit completed applications. It must be recognized that submission





of an application neither guarantees the applicant housing nor obligates the Agent to provide housing. Admission and move-in to the unit is contingent upon verified qualification of the applicant and availability of an appropriate unit. Management will serve a multi-family population.

A. Application Completion Procedures.

The date and time a complete application was submitted will be recorded on the waiting list and will establish priority for selection from the list. If an applicant submits an incomplete application, they must be notified in writing within 10 days of the items that are needed for the application to be considered complete and the priority will not be established until the additional items are received.

1. Written application, on properly prescribed form, must be made in order to be considered for residency.

2. Application must be made in person by the person(s) seeking the rental unit at the Manager's office on the Property unless the applicant meets the exception to this requirement noted in Section III. A. 4. Below.

Proof of identity such as driver's license, State identification card, etc. will be required of all applicants.

3. (Section 8 & Tax Credit properties only) every household member must sign a declaration of citizenship immigration status and must submit evidence of citizenship or immigration status. The application will not be considered complete until evidence of citizenship immigration status is provided. If the applicant cannot provide the necessary information, the owner may defer a final determination of eligibility until such time as the applicant provides such information. Only U.S. Citizens or eligible non-citizens may receive assistance. This means at least one family member must be able to provide proof of citizenship or eligible non-citizen status. If some family members are not able to provide proof of citizenship, assistance will be prorated accordingly, based on the number of confirmed eligible family members.

4. Applications may be submitted without personally appearing in the event that an interested party is physically disabled. Anyone may pick up an application at the Manager's Office and if necessary, an application will be mailed to interested persons. Should an applicant be unable physically come into the Office to complete the form:

a. The applicant shall be present to provide the required information to the person they have chosen to assist them in the completion of the application form.

b. The person assisting an applicant must sign and date the application along with the applicant, to indicate it was completed at the direction of the named applicant. The person will then deliver the application to the Manager's Office and provide proof of their identity to management.

5. The application must be completed in full. Any information required, but not readily available, must be so noted by the applicant on the application form.

a. Applicant will have ten (10) days to provide the information if immediate occupancy is anticipated.

b. Based on the waiting list, the applicant shall be given a time frame by the Manager, to bring in the required information.

c. Waiting List will remain open at all times and will never close.

B. Application Initial Screening Process/Interview for Move-in and Annual Recertification of Eligibility.

At the time application for rental is made, an initial screening interview will be conducted.

1. The application will be reviewed for completeness by the Management. Any applications which cannot be made complete at this time will be so noted by the Management and the applicant will be given a time frame to bring in the required information.

2. Proper identification will be obtained from the applicant by the Management and recorded.

3. Questions and concerns of the applicant will be answered by the Management.

4. The applicant will be provided a copy of the Resident Selection plan will be provided and the Management will explain the various stages of the waiting list process and the system for offering units.

5. All applicant household members must provide social security cards issued by the Social Security Administration. If the SS number is provided and a SS Card cannot be provided, the applicant will be allowed 90 days to obtain documentation and 6 months for occupants under the age of 6 in accordance with HUD regulations.





(For Section 8 Properties Only) For eligibility purposes, the requirement to disclose a Social Security Number is waived if no Social Security has been assigned and: a) A household member is 62 or older as of January 31, 2010 and eligibility determinations started before January 31, 2010 b) a household member is an ineligible non-citizen. The Social Security Number provided will be compared to the information recorded in the social Security Administration database (through HUD’s Enterprise Income Verification System) to ensure that the Social Security Number, birth date and last name match. If EIV returns an error that cannot be explained or resolved, assistance and/or tenancy may be terminated, and any assistance paid in error must be returned to HUD. If the applicant/resident deliberately provides an inaccurate Social Security Number, the owner/agent and/or HUD may pursue additional penalties due to attempted frauds.

6. (Section 8 Properties Only) All applicant household members must provide evidence of citizenship or eligible immigration status. Non-citizens (except those age 62 and older) must sign a Verification Consent Form and submit documentation of their status or sign a declaration that they do not claim to have eligible status.Mixed families (a family with one or more ineligible family members and one or more eligible family members) may receive either prorated assistance or a temporary deferral of termination of assistance.

7. All Adult members (age 18 and older) in the applicant/resident’s household must sign a tenant release and authorization at move-in and each year. (Section 8 Properties Only) All adult members (age18 and older) in the applicant’s family must sign HUD form 9887/9887A at move-in and every year thereafter.

8. The unit applied for, must be the applicants only residence.

9. Criminal, Credit and Rental background checks will be conducted for all applicants age 18 or older.

C. Record of Applications/Waiting List Procedures

1. Each applicant's name will be placed on the Record of Applications/Waiting List based on the date and time the application is received by the Management, which will be maintained by bedroom-size needs. The date and time a complete application was submitted will be recorded on the waiting list and will establish priority for selection from the list. If an applicant submits an incomplete application, they must be notified in writing within 10 days of the items that are needed for the application to be considered complete and the priority will not be established until the additional items are received. The following information will also be indicated on the Record of Applications/Waiting List:

a. Race/ethnicity.

b. Determination as to eligibility or ineligibility for selection based on eligibility and screening as noted in Section IV. of this Plan.

c. Date unit offered and if rejected, the reasons for the rejection.

d. Date assigned to a dwelling unit and identification of unit.

e. Reasons for moving applicant to an inactive status (if necessary).

2. Those applicants on the Record of Applications/Waiting List who have filed a complete application and have not been housed, but are still interested in housing, constitute the project's waiting list.

3. Waiting list remains open for eligible applicants at all times.

4. Applicants can be placed on multiple waiting lists for which the household qualifies based on occupancy standards. When an applicant is next on the waiting list, he or she can opt to accept the offered unit size or choose to remain on the waiting list for the other unit size.

D. Household income: The household income must not exceed the applicable housing program income limits for the property. All income limits are available and posted at the leasing office.

a. 60% of area median income level adjusted for family size (Tax Credit properties only) see table referenced below. b. Very-low-come level adjusted for family size (Section 8) c. Moderate-income level adjusted for family size (Section 515).


Page 4 of 10“This institution is an equal opportunity provider and employer”

“The owner/agent of this property complies with the Fair Housing Act and does not discriminate on the basis of race, color, religion, sex, national origin, disability, or familial status. The owner/agent also ensures that housing is available to all eligible persons regardless of actual or perceived sexual orientation, gender identity or marital status in

accordance with HUD’s Equal Access Rule.”Section 504 Coordinator: Alison Hunsicker, 4514 Cole Avenue, Suite 600 Dallas, TX 75205

T.D.D. 1-800-735-2989

INCOME LIMITSNumber of Household MembersIncome

Level 1 2 3 4 5 6 7 8Very Low $ 22,400 $ 25,600 $ 28,800 $ 31,950 $ 34,550 $ 37,100 $ 39,650 $ 42,200Low $ 35,750 $ 40,900 $ 46,000 $ 51,100 $ 55,200 $ 59,300 $ 63,350 $ 67,450

Moderate $ 41,250 $ 46,400 $ 51,500 $ 56,600 $ 60,700 $ 64,800 $ 68,850 $ 72,950

E. (Section 8) only citizens, or eligible non-citizens, are eligible for assistance as well as a discussion of a temporary deferral of termination of assistance, and provisions for pro-rating the rent for mixed families.

IV. Rejecting Applications.

A. Reasons Applications May Be Rejected.

1. Not meeting, or in certain programs exceeding, USDA and/or HUD criteria for the property.

2. Not meeting property screening criteria described in Section V. of this Plan.

3. Family composition does not conform to guidelines established by USDA and/or HUD for occupancy standards based upon the units available.

4. Applicant provided false information.

5. Students enrolled at an institution of higher education, under the age of 24, not a veteran, unmarried, and the do not have a dependent child, and that are seeking section 8 assistance in the individual capacity if neither the student nor the student’s parents are income eligible, demonstrate and is not a person with disabilities, as such term as defined in “sections 3(b)(3)(F) of the United States Housing Act of 1937 (42 U.S.C. 1437a (b)(3)(E)) ...” and was not receiving section 8 assistance as of November 30, 2005"

“A student under the age of 24 who meets the additional criteria of Section 327 of the Act may be income eligible for assistance in circumstances where an examination of the income of the student’s parents may not be relevant AND where the student can demonstrate the absence of, or his or her independence from parents by establishing a separate household from parents for at least a year.”

(Tax Credit) A student enrolled full time greater than 5 months in a calendar year in an institution of higher education and not meeting the following exceptions: married, have a dependent child, previously in foster care, and/or enrolled in a job training program.

6. The applicant’s annual income must not exceed the programs income limits up to the Low-income limit (Section 8 properties), Moderate-income limits (USDA Properties) or 60% limits (100% Tax-credit Properties).

7 The applicant is ineligible for occupancy in a particular unit or property (as described in the HUD Handbook 4530.3 Chapter 3, Sections 1 and 2 under eligibility requirements, IRS 8823 and USDA 3560)

8. The applicant is unable to disclose and document SSNs of all household members or (section 8 only) does not execute a certification stating that no SSNs have been assigned;

9. The applicant does not sign and submit verification consent forms or the Authorization for Release of Information (forms HUD-9887 and HUD-9887-A)

10. The household has characteristics that are not appropriate for the specific type of unit available at the time, or has a family of a size not appropriate for the unit sizes that are available. (In such cases, Management may deny the applicant admission to a specific unit, but the applicant may continue to wait for another unit.)

11. Applicant must agree to pay rent required by the program under which the family will be receiving assistance.


Page 5 of 10 “This institution is an equal opportunity provider and employer”



12. The unit for which the family is applying for must be the only residence.

13. Applicants who are subject to a state lifetime sex offender registration program, or are individuals whose abuse or pattern of abuse of alcohol and/or drug-related behavior that would interfere with the health, safety, or right to peaceful enjoyment of the premises by other residents.

B. Procedures for Rejecting Applicants

1. All applicants whose application is rejected will receive notification of the rejection in writing and the reasons for the denial of the application stated. The applicant will be allowed 7 days (TAA Applications/Leases) 10 days (USDA Properties) or 14 days (HUD Properties) to dispute the rejection. Within 5 business days of the response or meeting, management will advise the applicant in writing of the final decision on eligibility.

2. Applications needing additional data to qualify for housing will be sent a notice of conditional approval. This notice will be sent regular mail allowing the applicant 10 days (USDA Properties) or 14 days (HUD Properties) to respond to the request. Failure to respond in due time will disqualify the applicant.

V. Screening.

A. Screening Criteria.

All eligible applicants will be screened based on the following screening criteria. This criterion includes, but is not solely limited to:

Credit History:Banking and/or Credit information provided by applicant on their Rental Application must be found upon inquiry, by Management, to be true and correct. Information to be reviewed include but are not limited to:

(1) A court-created or court-affirmed obligation or judgment caused by non-payment that is currently outstanding or has been outstanding and in noncompliance with set terms, except:

(a) A bankruptcy in which: Debts were discharged prior to the date of application: or Where an applicant successfully completed a bankruptcy debt restructuring plan and has demonstrated a willingness to meet obligations when due for the 6 months prior to the date of application.

(b) A judgment satisfied more than 6 months before the date of application

(c) Child support with verification of wage garnishments or proof of consecutive payments for the past 6 months.

(2) An outstanding Internal Revenue Service (IRS) tax lien or any other outstanding tax liens with no satisfactory arrangement for payment.

(3) A foreclosure that has been completed within the last 36 months. Special consideration by Management will be made on a case by case basis. Items of consideration may include but are not limited to: divorce, death, loss of income etc.

(4) Outstanding collection accounts with a record of irregular payments with no satisfactory arrangements for repayment will be reviewed.

(5) Non-Agency debts written off within the last 36 months or are being considered for debt settlement. Agency debts that were debt settled within the past 36 months or are being considered for debt settlement. Any delinquency on a federal debt.

Mitigating circumstances – on a case-by-case basis we may waive or modify some criteria requirements based upon our reasonable judgment. For example, the credit history shows unfavorably due to a medical emergency, a contested divorce, etc.

Rental History:The applicant must have the ability to pay rent and adhere to the lease agreement. Verification of current and prior rental history will be obtained. Having no prior rental history, however, will not be a reason to deny an application. An application will be denied if there is:

History of nonpayment of rent History of violating the lease and rental agreements that would pose a threat to the property or other residents History of disturbing the neighbors An amount owed over $50, incurred during previous tenancies, unless the applicant can provide evidence the account has been paid





in full, had been making satisfactory payment agreement or received of a release from previous landlord. History of evictions and/or judgments against them regarding previous tenancies.

Applicants with no rental history and no credit history may provide letters from their family or a guardian certifying the applicant has never rented anywhere and has not established credit. Character references will be required if a rental history does not exist. Applicants in this category will be accepted for occupancy only if there is no derogatory credit; rental or criminal history found after the eligibility investigation is completed.

Criminal History:All applicants 18 and older will be subject to a criminal background check. Any household member’s behavior that is determined to potentially interfere with the health, safety, and right to peaceful enjoyment by other residents will be denied. Applicants that have been evicted (within the last 5 years) for drug related activity, or currently engaged in the use of illegal drugs or are subject to state sex offender lifetime registration requirements will be denied occupancy. In addition, applicants that have a criminal conviction, current indictment, adjudicated sentence and/or a pattern of criminal activity for any of the following MAY be denied occupancy depending upon the seriousness of the offense and the length of time since the conviction.

Theft; Burglary; Terrorist threat; Robbery; Fraud; Indecent exposure or any act of violence or sexual deviation that would constitute a danger to neighbors; Pattern of illegal use of alcohol and/or drugs, related convictions within the past 5 years; Convictions for the sale, manufacture or

distribution of drugs and/or alcohol; Crimes involving firearms or crimes against persons or property;

B. Special Considerations.

On a case-by-case basis, the owner/agent may consider extenuating circumstances in the screening process and while evaluating information obtained during the process to assist in determining the acceptability within 7 days. Factors to be considered in such a case will include:

1. The time, nature and extent of the applicant’s involvement and conduct.

2. Evidence of rehabilitation.

3. Evidence of applicant family's participation in, or willingness to participate in, social service or other appropriate counseling service programs and the availability of such programs.

4. Evidence of the applicant's willingness to attempt to increase family income and the availability of training or employment programs in the locality.

5. An indication that the family is likely to improve its financial situation because rent will be lower once the family is admitted subsidizing housing.

6. Circumstances leading to the offending action no longer exist.

7. The seriousness of the offense or the degree of participation in the offending activity by the household member.

8. The extent to which the applicant household has taken responsibility and takes all reasonable steps to prevent or mitigate the offending action.

9. The effect of the offending action on the program’s integrity.

VI. Selection and Waiting List Policy

Applicants determined eligible are selected based on income and chronologically from the appropriate bedroom size and/or type in which a vacancy exists. At the time a unit is offered the applicant will be required to provide all documentation needed to certify to the household’s income, assets, citizenship, number of occupants of the apartment, and other matters necessary to establish eligibility for occupancy.

Security Deposits: A security deposit equal to the amount of one month’s basic rent is due at time of move-in.(SECTION 8 PROPERTIES) A security deposit equal to the total tenant payment (TTP) is due at time of move-in.





Rent: All applicant’s if approved must agree to pay the required rent by the program under which the applicant will receive assistance.

Fees: A application of $12.50 and a key of $35 will be due at the time of move-in. *Please note the application fee is subject to change. Contact the leasing office for further information.

In addition, there are several areas where the applicant may be given priority consideration over that of another applicant.

A. Applicant Priority.

Selection from the completed applications on the waiting list shall be made in the following priority order.

1. Displaced (LOPE)

2. Extremely Low Income, (until 40% required by HUD is met on Section 8 properties).

3. Very Low Income,

4. Low Income,

5. Moderate-Income,

B. Income Targeting (Section 8 properties).

At least 40% of the assisted units that become available each year of this property’s fiscal year will be made available to families whose income does not exceed 30% of the area median income (extremely low income) at the time of admission.

VII. Assignment of Apartments.

Occupancy Standards and income limits are set by the following chart (Section 8 and Section 515 properties only):

Size of unitMinimum number of

residents Maximum number of residents1-bedroom 1 32-bedroom 2 53-bedroom 3 74-bedroom 4 9

A. System of Unit Offers.

1. Priority Transfers.

While the basic standards are to house all very low-income applicants prior to low and then moderate-income applicants, there are situations where this process may be bypassed. When a rental unit becomes available for occupancy priority will be given to the following eligible tenants in the housing project prior to selecting an eligible applicant from the waiting list. (Reference Transfer Policies for additional information)

a) If the unit is a handicapped accessible unit, then an eligible household that needs the features of that unit will receive priority over all other applicants, regardless of income.

b) Residents requiring transfers deemed necessary based upon certified medical conditions.

c) Residents requiring transfers deemed necessary based upon VAWA.

d) Over Housed: Residents that are housed in over-crowded conditions and have requested a larger unit appropriate for their household size bringing the household into compliance with the occupancy policy for the property.

e) Under Housed: Residents that are housed in a unit providing a greater number of bedrooms than warranted for their household size bringing the household into compliance with the occupancy policy for the property.





Management will retain a list by bedroom size of families that require unit transfers. The family name shall be placed on this list on the day the Manager becomes aware of the family composition change or other circumstances requiring a change.

An individual in one of the situations identified below would not be eligible for housing before applicants on the waiting list for a lower income category.

a) No longer a need for the accessible unit in which the household resides

b) Availability of Deeper Subsidy (For Tax-Credit Properties only)

c) Management convenience or for the safety of residents.

d) A resident who has given indication that they intend to move within the next few months need not be transferred. Any decision not to transfer a resident, however, should be documented and the resident notified in writing

2. Priority Applicants: .

a) Eligible applicants that meet the following conditions must be given priority for occupancy over all other tenants regardless of income. Such applicants, however, will be ranked among themselves by income level, giving priority first to very low-income households, then to low-income households, and finally to moderate-income households.i. Residents who require the special features of a unit accessible to individuals with disabilities only for the units

with these features. If more than one applicant needs the features of the accessible unit, then applicants who are very low-income would have priority, followed by low-income and then moderate-income households.

ii. The applicant has a letter of Priority Entitlement (LOPE) issued in accordance with 3560.660 (c)iii. The applicant was displaced from Agency-financed housing but was not issued a LOPE.iv. The applicant was displaced in a Federal declared disaster area.

b) An applicant will be offered an apartment of appropriate bedroom size and type. If there are no applicants for the appropriate bedroom size and type on the waiting list and no applications pending for the appropriate size an offer may be made to house an ineligible family in the available unit after prior approval.

Note: Eligibility is determined on a unit by unit basis in accordance with the priorities above.

B. Certification and lease process

1. If more than one such apartment is vacant, the applicant will be given a choice of all appropriately sized units.

2. All applicants 18+ must sign the Tenant Income Certification forms (HUD Forms 9887 and 9887A, USDA RD 3560-8, TDHCA TIC) at move in and at each annual recertification.

3. The unit must be the resident’s sole residence.

4. All applicant’s if approved must agree to pay the required rent by the program under which the applicant will receive assistance.

5. Non-Renewal & Termination of Occupancy (RRHA Lease Agreement)The owner shall terminate the lease and/or resident’s right to occupancy and evict the resident or refuse to renew the lease only for material noncompliance with the lease or other good cause (as defined below.)

MATERIAL NONCOMPLIANCE means one or more substantial violations of the lease; or nonpayment or repeated late payment of rent or other financial obligation due under the lease (or any portion thereof) beyond any grace period; or admission to or conviction for use, attempted use, possession, manufacture, selling, or distribution of an illegal controlled substance that: (i) is conducted in or on the premises by the resident or someone under the resident’s control; or (ii) is allowed to happen by a household member or guest because the resident has not taken reasonable steps to prevent or control such illegal activity; or (iii) because the resident has not taken steps to remove the household member or guest who is conducting the illegal activity.

GOOD CAUSE shall include but not be limited to (1) material noncompliance with the lease, (2) non-eligibility for tenancy, or (3) activity or conduct of any resident, household member, guest or invitee, that (a) threatens the health, safety, or right to peaceful enjoyment of the premises of other residents and owner/management, (b) threatens the health, safety, or right to peaceful enjoyment of the residences of persons residing in the immediate vicinity of the premises, or (c) has an adverse financial effect on the complex. Such prohibited activity or conduct includes any criminal activity, including the use or pattern of use of an illegal drug, and abuse or pattern of abuse of alcohol. The Owner may terminate the tenancy for such activity or conduct regardless of whether there has been an arrest or conviction and without satisfying a criminal standard of proof of the prohibited activity or conduct.





NOTICE OF VIOLATION. Owner will provide resident with notice of material lease violation or for other good cause. The notice will refer to the relevant portions of the lease stating the violation with sufficient detail to enable the resident to understand and correct the violation (if such violation involves the failure to pay rent, the notice shall state the dollar amount of the balance due and the date of such computation), shall state that the resident shall be expected to correct the violation by a specific date, shall state that the resident may informally meet with the owner to attempt to resolve the stated violation before the date of corrective action specified in the notice, and advise resident that if the action is not corrected by the specified date, the owner shall seek to terminate the lease by bringing a judicial action, at which time the resident may present a defense.

NOTICE OF TERMINATION. Upon the failure of resident to meet the conditions or correct the violation stated in the Notice of lease violation by the date specified therein, owner shall notify resident that the occupancy is terminated and that eviction is being sought through the appropriate judicial process. This notice shall comply with the State law and state the reason for the termination of occupancy, inform the resident of the rights under VAWA, provide a Tenant Grievance & Appeals Procedure, as well as the location and office hours during which the resident or resident’s counsel may review resident’s file and copy information to aid in the resident’s defense. The notice will also state how a person with disabilities may request a reasonable accommodation in relation to the notice provided.

C. Rental units accessible to individuals with disabilities.

If a rental unit accessible to individuals with disabilities is available and there are no applicants that required the features of the unit, borrower may rent to a non-disabled tenant subject to the inclusion of a lease provision that requires the tenant to vacate the unit within 30 days of notification from management that an eligible individual with disabilities requires the unit and provided the accessible unit has been marketed as an accessible unit, outreach has been made to organizations representing the disabled, and marketing of the unit as an accessible unit continues after it has been rented to a tenant who is not in need of the special design features.

D. Unit Rejection and Waiting List Position.

1. If the applicant rejects the vacancy offered, the applicant shall be placed at the bottom of the Waiting List.

2. Applicants may reject offers of vacancy without being moved from their place on the Waiting List in the case of hardship or handicapping condition, not related to race, color, religion, sex, familial status, or national origin.

3. Applicants who are willing to move, but unable to do so at the time of the offer will remain on the Waiting List in the order they applied. Management will determine the type of evidence required to establish the inability to move.

IX. Section 504 Statement

This property will seek to identify and eliminate situations or procedures that create a barrier to equal housing opportunity for all. In accordance with the Fair Housing Act and Section 504 of the Rehabilitation Act of 1973, the property will make reasonable accommodation for individuals with handicaps or disabilities (be it applicant or a resident). Such accommodations may include changes in method of administering policies, procedures, and/or services. In addition, when subject to Section 504 requirements, this property may perform structural modifications to housing and non-housing facilities (common areas) on site where such modifications would be necessary to afford all individuals full access to the housing program for qualified individuals with disabilities.

Any person expressing a desire to apply for a reasonable accommodation will be provided the appropriate forms by the leasing office; however, the reasonable accommodation request is not required to be in writing. When a request for reasonable accommodation is received, it will be forwarded to the 504 coordinator and reviewed in a prompt manner. If determine that additional information is needed, we will inform you in writing as soon as practicable and provide a reasonable time period for a response. Decisions on requests for reasonable accommodation shall be made within fourteen (14) days after the date on which the reasonable accommodation is received. If the Management denies a request for a reasonable accommodation, we will explain in writing the basis for its decision and reason why the request is being denied. The Property shall keep written records in resident or applicant files of its decisions to grant or deny any request for reasonable accommodation.

X. The Violence against Women Act

The Violence against Women Act (VAWA,P.L.09-62) and the Justice Department Reauthorization Act of 2005 protects housing assistance applicants and residents who have been victimized by domestic violence, dating violence, sexual assault, stalking and “affiliated individuals” of the victim as follows:

1. Applicants cannot be denied rental assistance solely because they were previously Evicted from an assisted site for being victims;





2. Applicants cannot be denied assistance solely for criminal activity or other acts against them that were directly related to being a victim of domestic violence, dating violence, sexual assault or stalking if the applicant otherwise qualifies for assistance or admission;

3. Residents cannot be evicted, or have their subsidies terminated solely because they were victims of domestic violence, dating violence, sexual assault and/or stalking; being a victim does not qualify as a “serious or repeated violation of the lease” or “other good cause” for eviction.

4. The domestic abusers may be evicted, and their names removed from leases. Remaining household members may continue residency as long as they are eligible.

5. In the event a transfer is required, Emergency Transfer Procedures are available in the leasing office.

Note: Certification of victim status is required, which includes names of abusers. Only victim service providers, medical professionals or attorneys who have counseled a victim can provide third-party verification of the applicant’s/resident’s status as a domestic violence victim.

You will be notified in writing (at the address specified by you) of your eligibility for occupancy. If you are determined eligible for occupancy and an apartment is not immediately available, you will be placed on a waiting list. When an apartment is available, you will be required to: 1) Sign a 1 year written lease; 2) Pay a security deposit in advance; 3) Pay the first month’s pro-rated rent in advance; 2) Make all required security deposits with the utility company to have the utilities transferred to your name; and 5) Complete a “move-in” inspection of the apartments with the manager.

Signing this acknowledgement indicates that you have had the opportunity to review the landlord’s Residents Selection Plan. The Resident Selection Plan may include factors such as criminal history, credit history, credit history, current income, and rental history. If you do not meet the selection criteria, or if you provided inaccurate or incomplete information, your application may be rejected and your application fee will NOT be refunded.

Resident Signature Date




Management Agent/Owner Signature Date

Montrose Place Apts



T.D.D. 1-800-735-2989

Attachments to the Application

I/We acknowledge receipt of:

Notice to Occupancy Rights Under the Violence Against Women Act (VAWA – HUD 5380)Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation (HUD 5382)

Applicant Signature Date




Management Agent/Owner Signature Date

NOTICE OF OCCUPANCY RIGHTS UNDERTHE VIOLENCE AGAINST WOMEN ACT

U.S. Department of Housing and Urban DevelopmentOMB Approval No. 2577-0286

Form HUD-5380(12/2016)

Montrose Place Apts Notice of Occupancy Rights under the Violence Against Women Act1

To all Tenants and Applicants

The Violence Against Women Act (VAWA) provides protections for victims of domestic

violence, dating violence, sexual assault, or stalking. VAWA protections are not only available

to women, but are available equally to all individuals regardless of sex, gender identity, or sexual

orientation.2 The U.S. Department of Housing and Urban Development (HUD) is the Federal

agency that oversees that the Section 8, Section 515 & LIHTC programs are in compliance

with VAWA. This notice explains your rights under VAWA. A HUD-approved certification

form is attached to this notice. You can fill out this form to show that you are or have been a

victim of domestic violence, dating violence, sexual assault, or stalking, and that you wish to use

your rights under VAWA.”

Protections for Applicants

If you otherwise qualify for assistance under the Section 8, Section 515 & LIHTC programs,

you cannot be denied admission or denied assistance because you are or have been a victim of

domestic violence, dating violence, sexual assault, or stalking.

Protections for Tenants

If you are receiving assistance under the Section 8, Section 515 & LIHTC programs, you may

not be denied assistance, terminated from participation, or be evicted from your rental housing

because you are or have been a victim of domestic violence, dating violence, sexual assault, or

stalking.

Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,

dating violence, sexual assault, or stalking by a member of your household or any guest, you

may not be denied rental assistance or occupancy rights under the Section 8, Section 515 &

1 Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual orientation.2 Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or marital status.

2

Form HUD-5380(12/2016)

LIHTC programs is solely on the basis of criminal activity directly relating to that domestic

violence, dating violence, sexual assault, or stalking.

Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom

you stand in the place of a parent or guardian (for example, the affiliated individual is in your

care, custody, or control); or any individual, tenant, or lawful occupant living in your household.

Removing the Abuser or Perpetrator from the Household

Montrose Place Apts may divide (bifurcate) your lease in order to evict the individual or

terminate the assistance of the individual who has engaged in criminal activity (the abuser or

perpetrator) directly relating to domestic violence, dating violence, sexual assault, or stalking.

If Montrose Place Apts chooses to remove the abuser or perpetrator, Montrose Place Apts may

not take away the rights of eligible tenants to the unit or otherwise punish the remaining tenants.

If the evicted abuser or perpetrator was the sole tenant to have established eligibility for

assistance under the program, Montrose Place Apts must allow the tenant who is or has been a

victim and other household members to remain in the unit for a period of time, in order to

establish eligibility under the program or under another HUD housing program covered by

VAWA, or, find alternative housing.

In removing the abuser or perpetrator from the household, Montrose Place Apts must follow

Federal, State, and local eviction procedures. In order to divide a lease, Montrose Place Apts

may, but is not required to, ask you for documentation or certification of the incidences of

domestic violence, dating violence, sexual assault, or stalking.

Moving to Another Unit

Upon your request, Montrose Place Apts may permit you to move to another unit, subject to the

availability of other units, and still keep your assistance. In order to approve a request, Montrose

Place Apts may ask you to provide documentation that you are requesting to move because of an

incidence of domestic violence, dating violence, sexual assault, or stalking. If the request is a

request for emergency transfer, the housing provider may ask you to submit a written request or

fill out a form where you certify that you meet the criteria for an emergency transfer under

VAWA. The criteria are:

3

Form HUD-5380(12/2016)

(1) You are a victim of domestic violence, dating violence, sexual assault, or

stalking. If your housing provider does not already have documentation that you

are a victim of domestic violence, dating violence, sexual assault, or stalking,

your housing provider may ask you for such documentation, as described in the

documentation section below.

(2) You expressly request the emergency transfer. Your housing provider may

choose to require that you submit a form or may accept another written or oral

request.

(3) You reasonably believe you are threatened with imminent harm from

further violence if you remain in your current unit. This means you have a

reason to fear that if you do not receive a transfer you would suffer violence in the

very near future.

OR

You are a victim of sexual assault and the assault occurred on the premises

during the 90-calendar-day period before you request a transfer. If you are a

victim of sexual assault, then in addition to qualifying for an emergency transfer

because you reasonably believe you are threatened with imminent harm from

further violence if you remain in your unit, you may qualify for an emergency

transfer if the sexual assault occurred on the premises of the property from which

you are seeking your transfer, and that assault happened within the 90-calendar-

day period before you expressly request the transfer.

Montrose Place Apts will keep confidential requests for emergency transfers by victims of

domestic violence, dating violence, sexual assault, or stalking, and the location of any move by

such victims and their families.

Montrose Place Apts’s emergency transfer plan provides further information on emergency

transfers, and Montrose Place Apts must make a copy of its emergency transfer plan available to

you if you ask to see it.

Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,

Sexual Assault or Stalking

4

Form HUD-5380(12/2016)

Montrose Place Apts can, but is not required to, ask you to provide documentation to “certify”

that you are or have been a victim of domestic violence, dating violence, sexual assault, or

stalking. Such request from Montrose Place Apts must be in writing, and Montrose Place Apts

must give you at least 14 business days (Saturdays, Sundays, and Federal holidays do not count)

from the day you receive the request to provide the documentation. Montrose Place Apts may,

but does not have to, extend the deadline for the submission of documentation upon your request.

You can provide one of the following to Montrose Place Apts as documentation. It is your

choice which of the following to submit if Montrose Place Apts asks you to provide

documentation that you are or have been a victim of domestic violence, dating violence, sexual

assault, or stalking.

A complete HUD-approved certification form given to you by Montrose Place Apts with

this notice, that documents an incident of domestic violence, dating violence, sexual

assault, or stalking. The form will ask for your name, the date, time, and location of the

incident of domestic violence, dating violence, sexual assault, or stalking, and a

description of the incident. The certification form provides for including the name of the

abuser or perpetrator if the name of the abuser or perpetrator is known and is safe to

provide.

A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or

administrative agency that documents the incident of domestic violence, dating violence,

sexual assault, or stalking. Examples of such records include police reports, protective

orders, and restraining orders, among others.

A statement, which you must sign, along with the signature of an employee, agent, or

volunteer of a victim service provider, an attorney, a medical professional or a mental

health professional (collectively, “professional”) from whom you sought assistance in

addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of

abuse, and with the professional selected by you attesting under penalty of perjury that he

or she believes that the incident or incidents of domestic violence, dating violence, sexual

assault, or stalking are grounds for protection.

Any other statement or evidence that Montrose Place Apts has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, Montrose

Place Apts does not have to provide you with the protections contained in this notice.

5

Form HUD-5380(12/2016)

If Montrose Place Apts receives conflicting evidence that an incident of domestic violence,

dating violence, sexual assault, or stalking has been committed (such as certification forms from

two or more members of a household each claiming to be a victim and naming one or more of

the other petitioning household members as the abuser or perpetrator), Montrose Place Apts has

the right to request that you provide third-party documentation within thirty 30 calendar days in

order to resolve the conflict. If you fail or refuse to provide third-party documentation where

there is conflicting evidence, Montrose Place Apts does not have to provide you with the

protections contained in this notice.

Confidentiality

Montrose Place Apts must keep confidential any information you provide related to the exercise

of your rights under VAWA, including the fact that you are exercising your rights under VAWA.

Montrose Place Apts must not allow any individual administering assistance or other services on

behalf of Montrose Place Apts (for example, employees and contractors) to have access to

confidential information unless for reasons that specifically call for these individuals to have

access to this information under applicable Federal, State, or local law.

Montrose Place Apts must not enter your information into any shared database or disclose your

information to any other entity or individual. Montrose Place Apts, however, may disclose the

information provided if:

You give written permission to Montrose Place Apts to release the information on a time

limited basis.

Montrose Place Apts needs to use the information in an eviction or termination

proceeding, such as to evict your abuser or perpetrator or terminate your abuser or

perpetrator from assistance under this program.

A law requires Montrose Place Apts or your landlord to release the information.

VAWA does not limit Montrose Place Apts’s duty to honor court orders about access to or

control of the property. This includes orders issued to protect a victim and orders dividing

property among household members in cases where a family breaks up.

Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or

Assistance May Be Terminated

6

Form HUD-5380(12/2016)

You can be evicted, and your assistance can be terminated for serious or repeated lease violations

that are not related to domestic violence, dating violence, sexual assault, or stalking committed

against you. However, Montrose Place Apts cannot hold tenants who have been victims of

domestic violence, dating violence, sexual assault, or stalking to a more demanding set of rules

than it applies to tenants who have not been victims of domestic violence, dating violence, sexual

assault, or stalking.

The protections described in this notice might not apply, and you could be evicted, and your

assistance terminated, if Montrose Place Apts can demonstrate that not evicting you or

terminating your assistance would present a real physical danger that:

1) Would occur within an immediate time frame, and

2) Could result in death or serious bodily harm to other tenants or those who work on the

property.

If Montrose Place Apts can demonstrate the above, Montrose Place Apts should only terminate

your assistance or evict you if there are no other actions that could be taken to reduce or

eliminate the threat.

Other Laws

VAWA does not replace any Federal, State, or local law that provides greater protection for

victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to

additional housing protections for victims of domestic violence, dating violence, sexual assault,

or stalking under other Federal laws, as well as under State and local laws.

Non-Compliance with The Requirements of This Notice

You may report a covered housing provider’s violations of these rights and seek additional

assistance, if needed, by contacting or filing a complaint with:

HUD, FHEO Office801 Cherry Street, Unit #45, Suite 2500Fort Worth, TX 76102817.978.5826

For Additional InformationYou may view a copy of HUD’s final VAWA rule at https://www.gpo.gov/fdsys/pkg/FR-2016-

11-16/pdf/2016-25888.pdf.

Additionally, Montrose Place Apts must make a copy of HUD’s VAWA regulations available to

you if you ask to see them.

https://www.gpo.gov/fdsys/pkg/FR-2016-11-16/pdf/2016-25888.pdf

https://www.gpo.gov/fdsys/pkg/FR-2016-11-16/pdf/2016-25888.pdf

7

Form HUD-5380(12/2016)

For help regarding an abusive relationship, you may call the National Domestic Violence Hotline

at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY).

For tenants who are or have been victims of stalking seeking help may visit the National Center

for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-

programs/stalking-resource-center.

Attachment: Certification form HUD-5382

https://www.victimsofcrime.org/our-programs/stalking-resource-center

https://www.victimsofcrime.org/our-programs/stalking-resource-center

Form HUD-5382(12/2016)

CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286 DOMESTIC VIOLENCE, and Urban Development DATING VIOLENCE,SEXUAL ASSAULT, OR STALKING, AND ALTERNATE DOCUMENTATION

Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and program participants in certain HUD programs from being evicted, denied housing assistance, or terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual orientation.

Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your housing provider may give you a written request that asks you to submit documentation about the incident or incidents of domestic violence, dating violence, sexual assault, or stalking.

In response to this request, you or someone on your behalf may complete this optional form and submit it to your housing provider, or you may submit one of the following types of third-party documentation:

(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an attorney, or medical professional, or a mental health professional (collectively, “professional”) from whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or “stalking” in HUD’s regulations at 24 CFR 5.2003.

(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or administrative agency; or

(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or tenant.

Submission of Documentation: The time period to submit documentation is 14 business days from the date that you receive a written request from your housing provider asking that you provide documentation of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing provider may, but is not required to, extend the time period to submit the documentation, if you request an extension of the time period. If the requested information is not received within 14 business days of when you received the request for the documentation, or any extension of the date provided by your housing provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or issuance of this form does not serve as a written request for certification.

Confidentiality: All information provided to your housing provider concerning the incident(s) of domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details shall not be entered into any shared database. Employees of your housing provider are not to have access to these details unless to grant or deny VAWA protections to you, and such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; or (iii) otherwise required by applicable law.

2

Form HUD-5382(12/2016)

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

1. Date the written request is received by victim: _________________________________________

2. Name of victim: ___________________________________________________________________

3. Your name (if different from victim’s):________________________________________________

4. Name(s) of other family member(s) listed on the lease:___________________________________

___________________________________________________________________________________

5. Residence of victim: ________________________________________________________________

6. Name of the accused perpetrator (if known and can be safely disclosed):____________________

__________________________________________________________________________________

7. Relationship of the accused perpetrator to the victim:___________________________________

8. Date(s) and times(s) of incident(s) (if known):____________________________________________________________________________________________________________

10. Location of incident(s):_____________________________________________________________

This is to certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction.

Signature __________________________________Signed on (Date) ___________________________

Public Reporting Burden: The public reporting burden for this collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information provided is to be used by the housing provider to request certification that the applicant or tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is subject to the confidentiality requirements of VAWA. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget control number.

In your own words, briefly describe the incident(s): ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________

Documents

No Walk-in’s – Office will be open for Appointments Only · No Walk-in’s – Office will be open for Appointments Only To schedule an appointment, please contact the leasing